by Leong Sze Hian
I refer to Goh Poh Kheng’s letter “Stumped by low MediShield payout” (ST, Mar 7).
To help Ms Goh and readers understand the use of Medisave and MediShield claims, I would like explain some of the queries raised by her. I shall also try to put all the relevant information in this article, as they seem to be all over the place – in various parts of the MOH and CPF web sites.
What is “pro-ration”?
Ms Goh wrote:
“I called the NUH billing department about it but they had no clue and advised me to call the Central Provident Fund (CPF) Board, which told me the amount to be calculated for the MediShield claim was not the full $2,300 submitted by NUH, but a sum after ‘pro-ration’, which came to $1,500.
I asked what this ‘pro-ration’ was and I was told it was calculated through means testing and for further details, I should call NUH.
I called the NUH patient service department and was told they would check with the CPF Board and get back to me. But, till now, no one has responded.
Who should I call now?
I wish such matters could be made more simple and transparent. A check on both the CPF Board and Ministry of Health (MOH) websites has left me none the wiser”
Actually, pro-ration (means testing) is explained in the MOH web site.
Briefly, if her father’s monthly income is more than $3,200, the 80 per cent subsidy will gradually reduce to 65 per cent when income exceeds $5,201.
For example, at $5,201, the patient would have to pay 75 per cent more than a patient whose income is below $3,200.
MediShield may also not cover 100 per cent of the medical fees, as there are various claim limits, such as Inpatient/Day Surgery rangng from $250 to $900 per day, depending on whether its a normal, ICU or Communiy Hospital ward; the type of Surgical Operations ranging from $150 (Table 1) to $1,100 (Table 7), etc.
For Outpatient Treatments, only the following types of treatment are covered, subject to the claim limits:-
- Chemotherapy for Cancer/Certain Benign
- Neoplasms – Per 7-day treatment cycle – $270; Per 21- or 28-day treatment cycle – $1240
- Stereotactic Radiotherapy for Cancer $1,800 per treatment
- Radiotherapy for Cancer
- External or Superficial – $80 per treatment day
- Brachytherapy with or without external – $160 per treatment day
- Kidney Dialysis – $1,000 per month
- Immunosuppressant drugs for organ transplant $200 per month
- Erythropoietin drug for chronic kidney failure $200 per month
Out-patient treatments that do not fall into the above definitions, or other illnesses, other that those listed above are not covered.
However, Medisave can be used for out-patient treatment of the following chronic illnesses, subject to withdrawal limits:-
- Hypertension, Lipid disorders (e.g. high cholesterol) and Stroke
- Asthma and Chronic Obstructive Pulmonary Disease (COPD)
- Mental illness (schizophrenia and major depression)
Medisave savings can be used for the following hospital charges:
- Daily ward charges
- Doctor’s fees
- Surgical operations including the use of operating theatres; and
- In-patient charges for medical treatment, investigations, medicines, rehabilitation services, medical supplies, implants and prostheses introduced during surgery
So, in summary, generally, out-patient treatment pre and post hospitalisation may not be covered for MediShield, and Medisave may also not be used for out-patient treatment unless they fall within the seven approved chronic illnesses.
The Deductible (Per Policy Year) which can be paid with Medisave or cash is as follows:-
- Members aged 80 years old and below – Class C $1000 Class B2 and above $1500
- Members aged between 81 – 85 years old – Class C $2000 Class B2 and above $3000
You can see that older patients aged between 81 to 85 years old have to pay double the deductible, which I find rather puzzling, as it is likely that more people may not be able to afford to pay at that advanced age.
The Co-insurance Amount is as follows:-
- Class C – $1001 – $3000 : 20%
- $3001 – $5000 : 15%
- Above $5000 : 10%
- Class B2 and above – $1501 – $3000 : 20%
- $3001 – $5000 : 15%
- Above $5000 : 10%
According to life expectancy tables, about 40 per cent of females and 20 per cent of males are expected to be alive at age 85. Therefore, the termination of MediShield cover at age 85, may mean that Singaporeans will have no cover when they need it most.
In addition, drugs and treatments that are non-subsidised items, will result in patients paying more out-of-pocket medical costs.
If it is an accident at work, public hospitals do not apply the usual subsidies. For example, a Class C patient may be charged up to five times more, and under the Workmen Injury Act, the employer is only resposible for up to $25,000 of medical expenses. In contrast, employers are required to insure foreign workers for $15,000, but have unlimited liability for their medical expenses.
The following is the List of Excluded Treatments & Medical Expenses :-
Generally, the following expenses are outside the scope of MediShield and cannot be claimed:
- Entire stay in hospital if the member was admitted to the hospital before he was insured by MediShield
- Treatment of any of the following categories of pre-existing illnesses or any other serious illnesses for which the patient had received medical treatment during the 12 months before the start of MediShield cover:
- Blood disorder
- Cerebrovascular accidents (stroke)
- Chronic liver cirrhosis
- Chronic obstructive lung disease
- Chronic renal disease, including renal failure
- Coronary artery disease
- Degenerative disease
- Ischaemic heart disease
- Rheumatic heart disease
- Systemic lupus erythematosus
- Ambulance fees
- Congenital anomalies, hereditary conditions and disorders e.g. hole-in-heart, hare-lip
- Cosmetic Surgery
- Maternity charges (including Caesarean operations) or abortions
- Dental work (except due to accidental injuries)
- Infertility, sub-fertility, assisted conception or any contraceptive operation
- Sex change operations
- Mental illness and personality disorders
- Optional items which are outside the scope of treatment
- Overseas medical treatment
- Private nursing charges
- Purchase of kidney dialysis machines, iron- lung and other special appliances
- Treatment for which the insured person received reimbursement from Workmen’s Compensation and other forms of insurance coverage
- Treatment of any illness, disability, injury or any condition arising from or due to the
- Acquired Immune Deficiency Syndrome (AIDS) virus
- Treatment for drug addiction or alcoholism
- Treatment of injuries arising directly or indirectly from nuclear fallout, war and related risk
- Treatment of injuries arising from direct participation in civil commotion, riot or strike
- Treatment of self-inflicted injuries or injuries resulting from attempted suicide
Finally, the last available statistic reported in the media a few years ago, was that about 750,000 people in Singapore, did not have any form of medical insurance.
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